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FW A FLORIDA W111ERS' COMPENSATION <br /> JOINT UNDERWRITING ASSOCIATION, INC. <br /> WORKERS COMPENSATION <br /> AND <br /> EMPLOYERS LIABILITY POLICY <br /> TYPE AR INFORMATION PAGE WC 00 00 01 ( A) <br /> POLICY NUMBER : ( 6FR1 3UB - 798BB04 - 4 - 05 ) <br /> RENEWAL OF ( GFR13UB - 7988B04 - 4 - 04 ) <br /> INSURER : FLORIDA W . C . JUA <br /> 1 NCCI CO CODE : 80179 <br /> INSURED : PRODUCER : <br /> HOMELESS FAMILY CENTER INC SCHLITT INS SVCS INC <br /> 715 4TH PLACE 1717 INDIAN RIV BLVD 300 <br /> VERO BEACH FL 32962 VERO BCH FL 32960 <br /> Insured is A CORPORATION <br /> Other work places and identification numbers are shown in the schedule (s) attached . <br /> 2 . The policy period is from 07 - 29 - 05 to 07 - 29 - 06 12 : 01 A. M . at the insured ' s mailing address . <br /> 3 . A . WORKERS COMPENSATION INSURANCE : Part One of the policy applies to the Workers <br /> Compensation Law of the state (s) listed here : <br /> FL <br /> a_ <br /> B . EMPLOYERS LIABILITY INSURANCE : Part Two of the policy applies to work in each state listed in <br /> m <br /> item 3 . A . The limits of our liability under Part Two are : <br /> Bodily Injury by Accident : $ 100000 Each Accident <br /> Bodily Injury by Disease : $ 500000 Policy Limit <br /> Bodily Injury by Disease : $ 100000 Each Employee <br /> C . OTHER STATES INSURANCE : Part Three of the policy applies to the states , if any , listed here : <br /> SEE ENDORSEMENT FWCJUA 03 01 <br /> N <br /> m <br /> 0 <br /> D . This policy includes these endorsements and schedules : <br /> o SEE LISTING OF ENDORSEMENTS - EXTENSION OF INFO PAGE <br /> 0 <br /> 4 . The premium for this policy will be determined by our Manuals of Rules , Classifications , Rates and Rating <br /> W— Plans . All required information is subject to verification and change by audit to be made ANNUALLY . <br /> DATE OF ISSUE : 08 - 01 - 05 SR ST ASSIGN : FL <br /> OFFICE : FLORIDA WC JUA 821 <br /> PRODUCER : SCHLITT INS SVCS INC 22WDC <br /> 008174 <br />